Preface

There are already plenty of
good books out there on introductory musculoskeletal radiology. Why did I write
this syllabus? Because, it seemed to me that most of these books were doing a
great job of telling one about diseases, but not how to approach their diagnosis.
Most books tell you the names of lots of disorders and the findings you see in
each of them. This is handy if you already know what disorder a patient has, and
you just want to learn more facts about it.

However when one starts out
looking at a film, one often has no idea what the diagnosis is. Experienced
musculoskeletal radiologists usually have no trouble generating an appropriate
differential diagnosis. But what do you do if you are just starting out in
radiology? While books like Reeder's or Taybi's list long differential diagnoses for
many findings in musculoskeletal radiology, the lists in these books are
usually fairly long, and are listed alphabetically, rather than in order of
prevalence. One of my favorite books as a resident was a book called Chest
Radiology - Patterns and Differential Diagnoses. Even though I am now a
musculoskeletal radiologist, I still use the updated version of this book
occasionally. In this book, the author, Dr. Reed, recognized that while
there are hundreds of potential diagnoses lurking out there for the chest
radiologist, in real life, one keeps bumping into the same old stuff over and
over, and only rarely finds cases of the unusual disorders.

Ninety percent of
the time, what one really needs, then, is some way to approach the 20 or 30
common presentations of disease. Dr. Reed's book presents 23 different problems
in chest radiology, and gives a real-world approach to working them up. I kept
hoping that someone would write something like this about musculoskeletal
radiology. Alas, no one else did. Nature abhors a vacuum, so this syllabus has
emerged to help fill this gap.

This syllabus, then, consciously tries to
emulate some of the overall philosophy of Dr. Reed's book. In it, I present
common, recurring problems in musculoskeletal radiology and how one can approach
them. The algorithms I present here have been consciously kept simple-minded.
Learning them will not make you a master of musculoskeletal diagnosis, nor will
you be ready to earn big bucks in the glamorous world of musculoskeletal
radiology. You certainly won't be ready to take the skeletal section of
radiology boards. BUT! You will be able to give an intelligent differential
diagnosis and imaging workup for about 90 % of what you see coming across the
average musculoskeletal board.

When I was interviewing for a residency
position, a wise old radiologist once told me in graphic detail of a theoretical
model that he had constructed of a radiology resident's mind. "Think of a
chicken-wire fence." he said. "You then take a bucket full of really runny used
chicken food and throw it up against the fence. Most of it runs off, but a
little bit sticks and dries. You repeat this process over and over, and you
finally end up with a lot of stuff built up there." The approaches in this book
are designed to act as that chicken-wire fence in your brain. So, keep reading
about musculoskeletal radiology and you'll end up with a lot of stuff built up
there.

This is a good place to add a caveat to the reader, in the form of
Sturgeon's Law. Before his death, Theodore Sturgeon was one of the very gods of
science fiction writing, and one of the many wise things that he said was:

"90% of everything in print is B. S.!"

Depending on how you feel about the stuff
that is currently in print in radiology books and journals, you may or may not
agree with this. If you are a believer in Murphy's Law, you may even feel that
Sturgeon was an optimist. Even if he was a bit pessimistic, there is an awful
lot of rubbish and bilge printed in textbooks and journals. What if you find,
someday, that parts of this syllabus are B.S.? First of all, congratulations on
developing your powers of discrimination to the point that you no longer blindly
believe everything you see in print. When you find what you consider to be
rubbish in this book, please let me know what it is and why you think so. Any
suggestions for improvements would be greatly appreciated. I'd like to learn
something from this process too.

So, take these approaches with a grain of
salt. They are not Revealed Truth, but they have worked for me and for many of
the residents that I have taught. I encourage you to add knowledge from other
sources to what you learn here, throw away the obvious nonsense, and end up with
The One True Way to approach these problems, which will, of course, be your
way.